A Question of Opioid Diversion or Compliance

A review of opioid metabolism at a higher level demonstrates that hydrocodone is further metabolized through different pathways to both dihydrocodeine and hydromorphone (3 ). [...]we hypothesized that given a higher chronic dose of codeine and a sensitive (low detection limit) assay that it would be possible for dihydrocodeine and hydromorphone to be present through the intermediate metabolic conversion of codeine to hydrocodone (Fig. 1). [...]the drugs of abuse testing volume has increased and recognition of the limitations of traditional immunoassay screens with reflex to confirmation algorithm has become more evident. [...]the possibility still exists that she could have also taken nonprescribed hydrocodone. 4) Are all the results of the initial testing consistent with the prescribed medications? TO REMEMBER * Morphine and hydrocodone are known metabolites of codeine and commonly found in the urine of patients who are using codeine as prescribed by their provider. * Dihydrocodeine and hydromorphone are less commonly detected in the urine of patients prescribed codeine as these are minor downstream metabolites. * Very high concentrations of codeine may be associated with the presence of trace amounts of dihydrocodeine and hydromorphone through the metabolic intermediaries of hydrocodone. * Sensitive mass spectrometry assays may also detect trace amounts of pharmaceutical impurities of opioids such as the presence of hydrocodone at ^1% of the oxycodone dose. * The correct interpretation of urine drugs of abuse testing requires knowledge of metabolic conversions, as well as an understanding of technical assay limitations. * Address correspondence to this author at: